Case Reports

Fixed screw‑retained interim restorations with immediate

implant placement in esthetic zone: A case series with six
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different techniques
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Udatta Kher, Pravinkumar G. Patil1, Ali Tunkiwala2, Smita Nimbalkar3

Private Practice, Dawn, 2Private Practice, Nirant, Khar, Mumbai, Maharashtra, India, 1Department of Prosthodontics, Division of Restorative
Dentistry, School of Dentistry, International Medical University, 3Division of Clinical Oral Health Sciences, School of Dentistry, International
Medical University, Kuala Lumpur, Malaysia

Abstract Postextraction immediate implant placement in the esthetic zone is a common treatment modality.
Immediate fixed interim restoration following immediate implant placement may provide excellent esthetic
results to the patients and boost the clinicians’ confidence. This paper demonstrates a series of six different
techniques used to fabricate the customized screw‑retained interim restorations following immediate
implant placement with partial extraction therapy in the maxillary anterior esthetic zone. The techniques
have utilized a putty index, polycarbonate shell crown, patients’ existing crowns (prosthetic or natural),
or laminate veneer, or fabricated in the laboratory based on the specific clinical situation. Advantages and
limitations of each technique including alternative techniques or materials have been discussed. Excellent
esthetic results were obtained with all six techniques using the screw‑retained immediate interim restorations
following partial extraction therapy and immediate implant placement.

Keywords: Immidiate implant, implant esthetics, interim restoration, provisional restoration

Address for correspondence: Dr. Pravinkumar G. Patil, Department of Prosthodontics, Division of Restorative Dentistry, School of Dentistry, International
Medical University, Jalan Jalil Perkasa‑19, Bukit Jalil, Kuala Lumpur 57000, Malaysia.
E‑mail: pravinandsmita@yahoo. co. in
Submitted: 19‑May‑2021, Revised: 11-Dec-2021, Accepted: 16‑Dec‑2021, Published: 27-Jan-2022

INTRODUCTION tremendous psychological trauma to the patients, especially

if it is in the esthetic zone (maxillary or mandibular anterior
Postextraction immediate implant placement in the esthetic region). Such clinical situations need urgent replacement
zone has gained popularity amongst clinicians as it boosts of the missing tooth/teeth. Immediate dental implant
patient satisfaction to a greater extent. [1,2] Advanced placement following extraction of such unsalvageable tooth/
periodontitis, unrestorable caries, fractures, and traumatic teeth is not a new concept and many clinical techniques and
injuries are the common reasons of immediate extraction procedures have been well evidenced.[1,2] The advantages
of the maxillary anterior teeth. In any of these clinical of single surgical procedure, that minimizes the overall
situations (especially in traumatic injuries) the unsalvageable treatment time, have encouraged clinicians to immediately
tooth or teeth usually required to be extracted. This may give
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How to cite this article: Kher U, Patil PG, Tunkiwala A, Nimbalkar S. Fixed
DOI: screw‑retained interim restorations with immediate implant placement in
10.4103/jips.jips_229_21 esthetic zone: A case series with six different techniques. J Indian Prosthodont
Soc 2022;22:97-103.

© 2022 The Journal of Indian Prosthodontic Society | Published by Wolters Kluwer - Medknow 97
 Kher, et al.: Fixed interim restorations for immediate implants

insert the implant fixtures into extraction sockets.[1] However, Different techniques have been demonstrated for single
various risk factors which may compromise the predictability unit immediate interim restorations using resin materials[10]
of the esthetic results should be assessed in detail before or patient’s own crown.[11] This paper demonstrates a series
commencing treatment procedures.[2] Sometimes, significant of 6 different techniques used to fabricate customized
tissue alterations could be observed at the surgical site which screw‑retained interim restorations following immediate
compromises clinical outcomes.[3] implant placement in the maxillary anterior esthetic zone.
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The techniques have utilized a putty index, polycarbonate

Immediate implant placement with immediate fixed shell crown, patients existing crowns (prosthetic or natural),
interim restoration in the esthetic zone results in excellent or laminate veneer or fabricated in the lab based on specific
short‑term treatment outcomes in terms of implant survival clinical situation.
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/14/2023

and minimal change of peri‑implant soft‑ and hard‑tissue

dimensions.[4] The volumetric facial contour changes of TECHNIQUES
immediately placed implants with and without immediate
interim restorations were studied in 40 participants and Six different techniques in six different patients have been
concluded that the restorations showed better volume described for fabricating a fixed screw‑retained interim
preservation in the esthetic zone at 1‑year follow‑up.[5] restorations onto the immediate implants placed in the
Another similar study compared facial mucosal levels with fresh extraction sockets in the maxillary anterior esthetic
and without immediate interim restorations and concluded zone. All patients were treated by partial extraction
that mid‑facial mucosal marginal level and papilla height therapy (also known as the socket‑shield technique).[12,13]
changes were minimal within groups, and no significant All implants had achieved optimal primary stability of more
differences were found between the two groups.[6] A than 35 NCm to place immediate restorations which was
systematic review was carried out on four studies with measured with an adjustable torque‑wrench (BioHorizons)
immediate implant placement, five studies with immediate during the surgery. All crowns were kept out of functional
implant restoration, and four studies with immediate occlusion (in both centric and eccentric occlusion) by
loading.[7] The authors concluded that immediately placed, 32 µm using multi‑layered shim‑stocks to avoid premature
restored, or loaded single‑tooth implants in the esthetic overloading during the osseointegration period.
zone result in similar hard and soft tissue changes compared
with conventional protocols. Technique 1: putty index and bis‑acryl resin
A 35‑year‑old woman reported with a history of repeated
There are mixed results in the literature regarding the dislodgement of her prosthetic crown on the maxillary
short‑term and long‑term peri‑implant soft‑ and hard‑tissue right central incisor. The tooth was endodontically treated
changes after immediate fixed interim restorations 17 years ago and had a postcore and crown restoration.
following immediate implants. Although postextraction The clinical and radiographic examination revealed that the
bone remodeling will occur irrespective of the timing of tooth was unrestorable and was indicated for extraction.
the implant placement, the time saved with immediate A polyvinyl siloxane putty index (Affinis; Coltene) was
placement and fixed immediate restoration indicated fabricated with the existing crown that was anatomically
the attractive treatment option with high subjective and intact before the extraction [Figure 1a]. Partial extraction
professional overall satisfaction.[1,2,8] Despite the satisfactory therapy followed by an immediate 4.2 mm × 15 mm
option, the maxillary anterior region still presents a sized tapered implant (BioHorizons) placement was
challenge for clinicians because of the inherent difficulties carried out under local anesthesia. A screw‑retained
encountered in the interim restorations and harmonious polyetheretherketone (PEEK) based interim abutment was
incorporation of the definitive prosthesis into patient’s placed on the implant [Figure 1b] and the hole was created in
dentogingival complex.[9] The maxillary ridge has facial the putty index corresponding to the abutment screw access
cortical bone that is more vulnerable to resorb as compared hole [Figure 1c]. The abutment screw access hole was closed
with the mandibular facial cortical bone because of the with the Teflon tape and an interim abutment was picked up
inherent difference in the bone density and the bone using a Bisacryl resin (Protemp 4; 3M ESPE) [Figure 1d].
resorption pattern. Surgical and restorative techniques The interim abutment was then attached to the laboratory
that can reduce the loss of hard and soft tissues that often analog and flowable composite resin (Z350 XT Flowable,
accompany implant placement are desirable. The use of a 3M ESPE) was added to fill up the voids and the emergence
customized interim restoration will provide a mechanism profile was shaped using composite finishing kit. The
to assist the clinician in achieving the preservation of hard interim restoration was finished and polished [Figure 1e]
and soft tissue.[10] and screwed onto the implant [Figure 1f].
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 Kher, et al.: Fixed interim restorations for immediate implants

Technique 2: polycarbonate shell crown with bis‑acryl polymerization, the excess resin that leaked out of the
resin crown contour was trimmed off. The voids were filled‑up
A 27‑year‑old woman reported with a history of with flowable composite resin [Figure 2d]. The restoration
trauma, leading to a fracture of her right maxillary was finished and polished using composite finishing and
central incisor [Figure 2a]. The root of the fractured polishing discs (Soflex, 3M ESPE) [Figure 2e] and the
tooth was removed with partial extraction therapy and a interim crown screwed onto the implant [Figure 2f].
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3.8 mm × 15 mm sized tapered implant (BioHorizons)

was placed. A PEEK‑based interim abutment was Technique 3: prosthetic (all ceramic) crown conversion
placed [Figure 2b]. The polycarbonate shell crown (3M A 55‑year‑old man reported with a dislodged prosthetic
ESPE) of the most appropriate size was selected from crown on the maxillary left canine [Figure 3a]. The tooth
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the available stock [Figure 2c] and tried over the abutment was endodontically treated 12 years ago and restored with
for possible adjustments and fitting. The crown was an all‑ceramic Lithium‑Disilicate (IPS e. max) crown.
perforated so that interim abutment popped out through Since the remaining tooth structure was nonrestorable,
it. An abutment‑screw access hole was closed with a the tooth was removed with partial extraction therapy and
Teflon tape and a Bisacryl interim material (Protemp 4; 4.2 mm × 15 mm sized tapered implant (Biohorizons)
3M ESPE) was filled inside the polycarbonate crown and was placed immediately. The PEEK interim abutment
some of the material was injected over the abutment to was placed on the implant [Figure 3b] and the crown
prevent voids. Alternately flowable composite resin can be was adjusted and perforated corresponding to the
used and cured through the shell crown. The screw was abutment screw access hole [Figure 3c]. The abutment
loosened completely to retrieve the interim crown. After was then picked up with Bisacryl resin (Protemp 4;

a b c

d e f
Figure 1: (a) Pretreatment view of the patient. (b) Immediate implant placed along with screw-retained polyetheretherketoe interim abutment. (c),
Pick up of crown with putty index. (d), Picked-up unfinished crown. (e), Finished and polished crown. (f), Posttreatment view

a b c

d e f
Figure 2: (a), Pretreatment intraoral view indicating fractured tooth at the gingival level. (b), Immediate implant placed along with screw-retained
polyetheretherketoe interim abutment. (c), Polycorbonate shell crown for pick up. (d), Picked-up unfinished crown. (e), Finished and polished
crown. (f), Posttreatment view

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 Kher, et al.: Fixed interim restorations for immediate implants

3M) as described in technique 3 [Figure 3d and e]. The composite resin (Z350 XT Flowable, 3M ESPE) was
finished and polished crown was screwed onto the injected in the gap between the veneer and the abutment
implant [Figure 3f]. and on the palatal side of the abutment. The flowable
composite resin was light polymerized and the whole
Technique 4: laminate veneer conversion interim crown was unscrewed and placed on the laboratory
A 42‑year‑old woman reported with a veneered analog [Figure 4e]. The excess resin was trimmed off,
tooth that was fractured at gingival level during a car finished, and polished [Figure 4f] and the crown was
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accident [Figure 4a]. The Lithium‑Disilicate (IPS e.max) screwed onto the implant [Figure 4g].
veneer was intact. Since the tooth was nonrestorable,
the partial extraction therapy was carried out with the Technique 5: natural crown conversion
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remaining root and 4.2 mm × 15 mm sized tapered A 46‑year‑old male visited with a concern of traumatic
implant (BioHorizons) was placed immediately in the injury to anterior teeth resulted in the fracture of his
socket. A PEEK interim abutment was placed over the maxillary right central incisor at gingival level and
implant [Figure 4b]. The veneer was carefully separated partial fracture of left central incisor [Figure 5a]. Since
from the bonded tooth by trimming the tooth portion the rest of the root portion of the right central incisor
from the palatal aspect using the diamond rotary was nonsalvageable, the partial extraction therapy was
instruments [Figure 4c] and positioned onto the interim carried out followed by immediate 4.2 mm × 15 mm
abutment. The height of the abutment was trimmed to sizes tapered implant placement (BioHorizons). The
accommodate the veneer [Figure 4d]. The intaglio surface Titanium interim abutment was placed [Figure 5b]. The
of the veneer was sequentially treated with hydrofluoric broken natural crown was trimmed from the palatal
acid etchant, the silane coupling agent, and the bonding aspect to keep the facial surface intact [Figure 5c] and
agent in conventional manner. The abutment screw positioned in relation to the interim abutment. The
access hole was closed with Teflon tape and the flowable height of the abutment was trimmed to accommodate

a b c

d e f
Figure 3: (a), Patient’s dislodged all-ceramic crown. (b), Immediate implant placed, and screw-retained polyetheretherketoe interim abutment
adjusted to fit the crown. (c), All ceramic crown adjusted and perforated for abutment screw access. (d), Minor modifications done on the picked-
up unfinished crown. (e), Finished and polished crown. (f), Posttreatment view

a b c d

e f g
Figure 4: (a), Pretreatment intraoral view indicating fractured tooth at gingival level. (b), Immediate implant placed along with screw-retained
polyetheretherketoe interim abutment. (c), Patient’s laminate veneer. (d), Veneer and interim abutment adjusted. (e), Picked-up unfinished crown.
(f), Finished and polished crown. (g), Posttreatment view

100 The Journal of Indian Prosthodontic Society | Volume 22 | Issue 1 | January-March 2022
 Kher, et al.: Fixed interim restorations for immediate implants

the crown [Figure 5d]. The crown was sequentially DISCUSSION

treated with a phosphoric acid etchant and a bonding
agent and subsequently picked up along with the All the screw‑retained interim restorations were replaced
interim abutment using flowable composite resin with functional definitive restorations after 4–6 months
similar to technique 4 [Figure 5e]. After finishing and of osseointegration period. All provisional crowns
polishing [Figure 5f], the interim crown was screwed revealed esthetically pleasing peri‑implant mucosal contour
without any clinically evident difference between any
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onto the implant [Figure 5g].

2 techniques [Table 1]. Even though all patients were
Technique 6: laboratory fabricated or indirect treated by partial extraction therapy,[12,13] the restorative
In situations, where the patient can wait for couple of techniques remain the same for conventional extraction
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days to receive fixed interim restoration or already using and immediate implants placement (with or without bone
removable partial denture, a laboratory fabricated interim grafts). The advantages and limitations of each technique
restoration can be planned. The maxillary right central are summarized in Table 1. Anterior tooth extractions
incisor of a 65‑year‑old male was fractured at the cervical typically require the execution of single‑unit prostheses
level [Figure 6a]. The root was removed with partial using composite resins or polymers like Bisacryl resins.
extraction therapy and an implant (Biohorizons) of size In the first technique, the putty index was used to copy
4.2 mm × 15 mm was placed immediately in the socket the external surface form of the crown. In situations of
[Figure 6b]. A closed tray (alternately open tray can be damaged crown structure, a waxed‑up cast can be used to
used) impression of the implant was made [Figure 6c]. prepare the index. The use of thermoformed sheet can be
The final stone cast was fabricated, and an interim another alternative option for the putty index [Table 1].
crown was fabricated with composite resin in the However, it needs an extra step of fabrication of a stone
laboratory [Figure 6d]. The interim crown was screwed cast for the adaptation of the thermoformed sheet.
onto the implant [Figure 6e]. The second technique utilized a polycarbonate shell

a b c d

e f g
Figure 5: (a), Pretreatment intraoral view indicating fractured tooth at the gingival level. (b), Immediate implant placed along with screw-retained
interim abutment. (c), Coronal portion of patient’s fractured natural tooth. (d), Natural crown portion and interim abutment adjusted. (e), Picked-up
unfinished crown. (f), Finished and polished crown. (g), Posttreatment view

a b c

d e
Figure 6: (a), Pretreatment intraoral view indicating fractured tooth at the gingival level. (b), Immediate implant placed. (c), Impression coping
placed. (d), Finished and polished crown fabricated completely in lab. (e), Posttreatment view

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 Kher, et al.: Fixed interim restorations for immediate implants

Table 1: Different techniques used to fabricate interim restorations onto immediate implants with their alternatives,
advantages, and limitations
Techniques used Alternative techniques Advantages Limitations
or materials
Technique 1: Putty Quick No visibility during pick up of interim restoration
index and Bisacryl Need waxed‑up cast if tooth anatomy not intact
resin Thermoformed template Transparent with good visibility during Need duplicated cast to adapt the
pick up of interim restoration thermoformed sheet
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Technique 2: With flowable composite Quick Need to keep in stock

Polycarbonate shell resin Varieties of sizes and shapes available Need careful finishing
crown with Bisacryl Well finished and polished surface
resin Cellulose‑acetate crown Quick Need to keep in stock
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forms Limited sizes or shapes available

Technique 3: Prosthetic Esthetic Limited to the specific patient who need
crown conversion Quick extraction of tooth with prosthetic crown
Technique 4: Laminate Esthetic Limited to the specific patient who need
veneer conversion Quick extraction of tooth with the veneered crown
Technique 5: Natural Esthetic Limited to specific patient who needs extraction
crown conversion Quick of tooth with natural crown
Technique 6: Lab Reduced chair time Need additional impression procedure
fabricated or Indirect Well‑formed, finished, and polished Cannot be immediately restored
restoration need to wait for consuming
Lab cost involved

crown, available in stock. Alternately transparent flexible consideration is an integral parameter of any implant
Cellulose‑Acetate crown forms can be used. These crown treatment. This becomes even more critical especially
forms need to be removed after polymerization. with the maxillary anterior region as the contours of are
important aspect of the anterior guidance in mandibular
The resin‑based interim restorative materials, however, movements.
may not always provide promising esthetic results. Use
of patient’s original crown portion, (natural crown or Partial extraction therapy was used to treat all six
restored either with prosthetic crown or laminate), if patients.[12.13] Recent developments involving partial root
can be used, may provide good esthetic results as the retention minimize the negative effects of extraction
original tooth shape and color is maintained.[11] This may and offer enhanced buccal tissue contour in these
also boost the patient’s confidence. The use of coronal cases.[13] However, each step of the treatment from tooth
portions of patients’ original teeth has been utilized for extraction to the definitive restoration should be performed
immediate implant interim restorations in technique 3 (with meticulously to achieve a good esthetic outcome. One
all‑ceramic crown), technique 4 (with veneered crown), of the most critical parameters in immediate implant
and technique 5 (with natural crown). Excellent esthetic placement is primary stability. Fixed interim restoration can
results were achieved, and patients left home with their only be tried in situations where the primary stability of
own original coronal portion fixed onto the implants. the implant is in clinically acceptable limits (usually more
In some clinical situations, the patient can return for than 35 NCm). The selection of relatively longer implants
the interim restoration within 24–72 h after surgery and may facilitate increasing primary stability in such situations.
thus, the laboratory fabricated interim restoration can be In most of the patients described, we have used 15 mm
planned. The laboratory fabricated interim crown was length of the implants for the same reason.
described in technique 6 that has provided excellent esthetic
results [Figure 6e]. SUMMARY

The alternative options to the fixed interim restorations This report demonstrated six techniques using screw
could be any of the following including the removable retained immediate interim restorations following
partial dentures, Essix retainers, or bonding the resin‑tooth partial extraction therapy and immediate implant
to adjacent teeth. However, to maintain the hard and placement. The fabrication techniques have utilized a
soft tissue form and esthetics, fixed interim restoration putty index, polycarbonate shell crown, patients’ existing
can be preferred. The cement‑retained implant interim crowns (prosthetic or natural), or laminate veneer or
restorations can also be used alternatively. However fabricated in the laboratory based on the specific clinical
excessive cement, if logged in the crestal region, could situations. Excellent esthetic results were obtained in all
be potential irritant to the healing tissues. Occlusal six patients treated.
102 The Journal of Indian Prosthodontic Society | Volume 22 | Issue 1 | January-March 2022
 Kher, et al.: Fixed interim restorations for immediate implants

Declaration of patient consent Raghoebar GM. Immediate placement of dental implants in the
esthetic zone: A systematic review and pooled analysis. J Periodontol
The authors declare that they have obtained consent from
2014;85:e241‑50.
patients. Patients have given their consent for their images 5. Wang IC, Chan HL, Kinney J, Wang HL. Volumetric facial contour
and other clinical information to be reported in the journal. changes of immediately placed implants with and without immediate
Patients understand that their names will not be published provisionalization. J Periodontol 2020;91:906‑16.
6. Chan HL, George F, Wang IC, Suárez López Del Amo F, Kinney J,
and due efforts will be made to conceal their identity but Wang HL. A randomized controlled trial to compare aesthetic
anonymity cannot be guaranteed.
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outcomes of immediately placed implants with and without immediate

provisionalization. J Clin Periodontol 2019;46:1061‑9.
Financial support and sponsorship 7. Yan Q, Xiao LQ, Su MY, Mei Y, Shi B. Soft and hard tissue changes
Nil. following immediate placement or immediate restoration of
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/14/2023

single‑tooth implants in the esthetic zone: A systematic review and

meta‑analysis. Int J Oral Maxillofac Implants 2016;31:1327‑40.
Conflicts of interest 8. Hartlev J, Kohberg P, Ahlmann S, Andersen NT, Schou S, Isidor F.
There are no conflicts of interest. Patient satisfaction and esthetic outcome after immediate placement
and provisionalization of single‑tooth implants involving a definitive
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